Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Enniscourt Nursing Care during CMS and state inspections, most recent first.
A resident with significant cardiac history repeatedly used the call light overnight, reporting chest pain and chest tightness to multiple CNAs, who observed the resident in apparent distress and notified an RN. The RN reviewed orders, administered PRN Maalox for presumed indigestion, and reported taking but not documenting vital signs, with no documented assessment or evidence of physician notification despite ongoing complaints. Call light activity continued approximately every 20 minutes, yet the record lacked timely assessment or monitoring entries until the RN later documented that the Maalox was effective. In the early morning, the RN found the resident unresponsive in bed, 911 was called, CPR was initiated, and EMS arrived to find the resident pulseless with rigor mortis and mottling, later pronouncing death. Surveyors found that the facility failed to adequately assess and document the change in condition, respond appropriately to repeated chest pain complaints, and follow its acute condition change protocol.
A resident with significant cardiac history repeatedly used the call light and complained of chest pain and chest tightness during the night. CNAs reported these complaints and the resident’s apparent distress to an RN, who administered PRN Maalox for presumed indigestion, took but did not document vital signs, and later documented the PRN as effective despite no recorded assessment around the time of administration. The resident was later found unresponsive in bed without vital signs, and EMS arrived to find rigor mortis, mottling, and asystole before a physician pronounced death. The next day, a CNA reported to the DON and Administrator that the nurse had not done anything regarding the resident’s chest complaints, but leadership did not treat this as an allegation of neglect and did not report it to the State agency as required by facility policy, resulting in a cited failure to report suspected neglect.
A resident with dementia and significant care needs was not protected from misappropriation when a former CNA took a check from the resident's checkbook and attempted to deposit it for $3,225. The incident was discovered after the resident's daughter was notified by the bank, and facility investigation confirmed the check was missing and matched the former CNA's handwriting. The facility was unaware of the missing check until informed by the resident's daughter, and the police were notified.
A facility failed to transcribe and administer oxygen orders correctly for a resident with multiple health issues, including congestive heart failure. The resident was admitted with hospital instructions for continuous oxygen, but the facility recorded it as PRN, leading to improper administration. Interviews revealed a lack of awareness of the continuous order, and records showed oxygen was not administered on certain dates. An autopsy indicated the resident did not receive oxygen for five hours, contributing to their death.
The facility failed to submit accurate staffing information to CMS, affecting all 39 residents. The PBJ report indicated a lack of 24-hour licensed nursing coverage on specific dates, but facility schedules showed otherwise. Inconsistencies were found between actual time punches and the submitted report, confirmed by the Financial Officer and Administrator.
Failure to Assess and Respond to Repeated Chest Pain Complaints After Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with significant cardiac history. The resident had diagnoses including acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. The admission MDS showed the resident had intact memory, modified independence for decision-making, and required varying levels of assistance with ADLs. Physician orders included PRN Maalox for antacid use, but there were no PRN orders for chest pain. On the night in question, the resident repeatedly used the call light beginning around 11:07 P.M. and continuing into the early morning hours. CNA staff reported that the resident complained multiple times of chest pain and chest tightness and appeared to be in distress. CNA #208 stated the resident first complained of not having had a bowel movement since the hospital, was assisted with a bedpan, and later had a large bowel movement. About 20 minutes after that, the resident complained of chest pain, which CNA #208 reported to RN #207. CNA #208 stated the nurse did not get up right away, and after another call light and another complaint of chest pain, she again informed RN #207, who responded that she had given Maalox and the resident needed to give it time to work. CNA #208 and other CNAs reported that the resident continued to ring the call light approximately every 20 minutes, repeatedly complaining of chest pain and, at one point, chest tightness. CNA #136 and CNA #153 also reported that the resident complained of chest tightening or chest tightness and looked like he was in distress, and they informed RN #207. RN #207 stated that when informed of the complaint, she reviewed the physician’s orders, saw only PRN Maalox, and then went to see the resident. She reported that the resident described indigestion, that she administered PRN Maalox, and that she took his blood pressure, which was initially elevated and then normal after repositioning, but she did not document these vital signs or an assessment in the medical record. The eMAR showed Maalox was administered at 12:28 A.M., but there was no documentation of an assessment, vital signs, or chest pain at that time. The device activity report showed multiple call light activations between 11:07 P.M. and 12:48 A.M. RN #207 later documented at 4:21 A.M. that the Maalox was effective, but there was no corresponding assessment or vital signs documented. She stated that at some point she saw the resident sleeping and did not recall the time. Around the time of her medication pass, she noticed the resident did not look right, entered the room, and found him unresponsive, at which point 911 was called and CPR initiated. The EMS run report documented that EMS was dispatched shortly after 5:14 A.M. and arrived to find the resident unresponsive, not breathing, pulseless, with rigor mortis in the jaw and mottling throughout the body. Nursing staff told EMS that the resident had complained of chest pain earlier in the night and that they had checked on him at 4:00 A.M. The resident was wearing a Full Code wristband, and EMS confirmed asystole in multiple leads before a physician pronounced death at 5:28 A.M. Review of the facility’s Acute Condition Changes-Clinical Protocol showed that nurses are to assess and document baseline information such as vital signs, pain level, and changes in condition, and that direct care staff are to be trained to recognize and report significant changes to the nurse. Despite this policy, there was no documented evidence that the resident’s repeated complaints of chest pain and tightness were adequately assessed, that vital signs and assessments were documented, or that the physician was notified of the change in condition, leading to the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals following an acute change in condition.
Removal Plan
- Remove RN #207 from work.
- Review the change in condition policy with the DON and Administrator before staff education.
- Review records of all residents for changes in condition to ensure they are properly reported and addressed.
- Run a report for all residents with cardiac diagnoses and review for any need for reassessment or recent change in condition.
- In-service all certified nursing assistants (CNA) on the need to immediately notify the nurse if there is a change in condition or emergency and on the facility protocol for obtaining assistance during an emergency situation, including what to do if a nurse is unavailable or not responding.
- Instruct CNAs to escalate up the chain to the charge nurse or DON if a nurse is unavailable or not responding.
- Do not permit any CNA to work until in-servicing is completed.
- In-service all licensed nurses on the facility policies and procedures related to change in condition, appropriate assessments and documentation, timely notification to physician of change in condition, and how to respond to emergency situations.
- Do not permit any licensed nurse to work until in-servicing is completed.
- Hold an ad hoc QAPI meeting with the Medical Director, Administrator, DON, and nursing staff to discuss the incident, follow-up measures and action plan, and to review relevant policies.
- Begin monitoring all shift reports and nurse's notes to ensure all changes in condition are timely reported to the physician and appropriately addressed.
- Conduct audits daily for two weeks and then three times a week for six weeks.
- Have the QA Committee monitor the results of the audits and follow up as needed.
Failure to Report Allegation of Neglect After Repeated Chest Pain Complaints and Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State agency after a resident experienced repeated complaints of chest pain prior to death. The resident had diagnoses including acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. On admission assessment, the resident’s memory was intact, he had modified independence for daily decision-making, required supervision with eating, was dependent for toileting hygiene, and needed partial/moderate assistance with bed mobility and transfers. The resident had a PRN order for aluminum and magnesium hydroxide suspension for antacid but no PRN orders for chest pain. On the night in question, the electronic MAR showed that an RN administered PRN Maalox around 12:28 A.M. and later documented at 4:21 A.M. that the medication was effective. However, there was no documented assessment or vital signs around the time of Maalox administration in the medical record. A health status note at 5:13 A.M. documented that the resident was found in bed without vital signs, 911 was called, CPR was initiated, and EMS and police arrived. The EMS run report indicated EMS was dispatched shortly after 5:14 A.M. and arrived to find the resident unresponsive, not breathing, pulseless, with rigor mortis and mottling present, and asystole confirmed in multiple leads; a physician pronounced death at 5:28 A.M. A device activity report showed the resident activated the call light multiple times between approximately 11:07 P.M. and 12:48 A.M. Interviews with staff revealed that multiple CNAs reported the resident’s complaints of chest pain or chest tightness to the RN. One CNA stated the resident repeatedly complained of chest pain and appeared in distress, and that she informed the RN twice, while other CNAs also reported chest tightness or chest pain to the RN. CNAs described the resident as frequently using the call light and verbally expressing chest discomfort, with one CNA stating the resident looked like he was in distress and had his hand on his chest. The RN reported that the resident described indigestion, that she administered Maalox, took and retook blood pressure (which she did not document), and later observed the resident sleeping. The facility’s abuse/neglect policy required that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and injuries of unknown source be reported immediately to the Administrator or designee and to the State agency within 24 hours. The Administrator and DON both acknowledged that a CNA reported concerns that the nurse did not act on the resident’s complaints, but they did not report this allegation to the State agency, leading to the cited failure to report an allegation of neglect. The Administrator stated that she was aware of the CNA’s account that the resident had complained of chest discomfort and that the nurse did not seem concerned or take action, and that the CNA was telling others that the nurse did nothing regarding the complaints. The Administrator explained that she did not report the matter to the State agency because she perceived the CNA’s statements as characterizing the nurse as lazy rather than as a true concern. The DON similarly stated that the CNA came to her the very next day and reported that the nurse did not do anything regarding the resident’s complaints of pressure and discomfort, but the DON also did not report this to the State agency. Despite the facility’s written policy requiring immediate reporting of allegations of neglect to the Administrator and to the State agency within 24 hours, there was no evidence that this allegation was reported, constituting the deficiency.
Failure to Protect Resident from Misappropriation of Funds by Former CNA
Penalty
Summary
A deficiency occurred when a resident with dementia and multiple chronic conditions, who required extensive assistance with activities of daily living, was not protected from misappropriation of property. The resident's daughter discovered that a check from the resident's account, in the amount of $3,225, had been written and attempted to be deposited by a former Certified Nursing Assistant (CNA) who was previously employed at the facility. The check was flagged by the bank, and no funds were transferred. The incident was reported to the facility by the resident's daughter after being notified by the bank. The facility's investigation revealed that the check was missing from the resident's checkbook, with the check number sequence confirming only one check was unaccounted for. The check was made out to the former CNA and bore a signature matching the CNA's handwriting, as confirmed by the DON. The CNA had worked night shifts and was terminated for unrelated attendance issues prior to the incident being discovered. The facility was unable to determine exactly when the check was taken, but it was possible the CNA took it while the resident was sleeping. The facility's policy defined misappropriation as the wrongful use of a resident's belongings or money without consent, and the incident was substantiated as misappropriation. The police were notified, and a theft report was filed. The facility was not aware of the missing check until contacted by the resident's daughter, and the resident's checkbook was subsequently secured in the office, with access provided as needed.
Failure to Transcribe and Administer Oxygen Orders Correctly
Penalty
Summary
The facility failed to correctly transcribe and record oxygen orders for a resident upon admission, leading to improper administration of oxygen. The resident, who had multiple diagnoses including congestive heart failure and chronic obstructive pulmonary disease, was admitted with hospital discharge instructions for continuous oxygen at 2 liters per minute. However, the facility's physician orders only included PRN (as needed) oxygen to maintain saturation above 92%, which did not match the continuous oxygen requirement from the hospital. Interviews revealed that the previous Director of Nursing (PDON) was responsible for transcribing the orders and typically entered oxygen as a PRN order unless otherwise specified. The PDON was unaware of the continuous oxygen order from the hospital. The Medication Administration Record showed that oxygen was not signed off as administered on two specific dates. Family members reported that an autopsy indicated the resident did not receive oxygen for five hours, and the death certificate listed cardiorespiratory failure as a cause of death.
Inaccurate Staffing Information Submitted to CMS
Penalty
Summary
The facility failed to submit accurate staffing information to the Centers for Medicare and Medicaid Services (CMS), which had the potential to affect all 39 residents residing in the facility. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter one for 2024 indicated that the facility did not have licensed nursing coverage 24 hours per day on several specific dates in December 2023. However, a review of facility schedules and assignment sheets for those dates showed that nursing staff was present 24 hours each day. Further review of the December 2023 timecard punch details report submitted for the PBJ report revealed inconsistencies between the actual time punches and the information on the submitted report. An interview with the Financial Officer (FO) and the Administrator confirmed these inconsistencies, as the FO had run a report from their timecard system and uploaded it for the PBJ quarterly report submission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestmont North Nursing Home | 0 mi | ★★★★★ | 5 | 0 |
| O'neill Healthcare Lakewood | 0.3 mi | ★★★★★ | 3 | 0 |
| Rocky River Gardens Rehab And Nursing Ctr | 3.5 mi | ★★★★★ | 7 | 0 |
| Larchwood Care | 3.5 mi | ★★★★★ | 16 | 0 |
| Franklin Plaza Extended Care | 3.6 mi | ★★★★★ | 39 | 0 |
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